Internal Coverage Criteria for Medical Services
When reviewing a prior authorization request, Devoted Health uses InterQual™ clinical criteria for the services and procedures listed in this policy: Services reviewed using InterQual criteria (PDF)
See InterQual’s detailed coverage criteria. (Note: you'll need to create an Optum One Healthcare ID account to access the criteria.)
Learn about InterQual’s development process (PDF)
For cases when coverage criteria are not fully spelled out in these resources, we created internal coverage criteria based on current evidence in widely used treatment guidelines or in publicly available clinical literature.
Medical Services
Cardiac Catheterization & Coronary Angiography Clinical Criteria
Elective Inpatient Requests Not on CMS IPO List
Galleri® Test by Grail Labs Technology Assessment
High Intensity Focused Ultrasound Ablation for Prostate Cancer
Home Infusion Therapy Services
Intraosseous Nerve Ablation Technology Assessment
IRE Ablation for Prostate Cancer
Minimal Residual Disease Testing for Cancer
MyoPro Orthotic Device Technology Assessment
Non-emergent Ambulance Transportation
Skin Substitute Grafts for Treatment of DFU and VLU
Superion Interspinous Spacer System Technology Assessment